Public Health’s ten year victory over tobacco

Today, February 27th 2015, marks the tenth anniversary of the coming into force of the WHO Framework Convention on Tobacco Control (#FCTC10). To mark the historic treaty's first decade the WHO's Director-General, Dr Margaret Chan, gave an address in which she called the FCTC the 'single most powerful preventive instrument available to public health'. She wasn't exaggerating. I'll tell you why.

The FCTC was the first, and remains the only, legallybinding multilateral agreement ratified by WHO member states. Most of WHO's directives are delivered with the all the authority of a global governance institution but with none of the legal teeth that multilateral trade agreements, for example, enjoy. WHO has had treaty-making power since its creation in 1948. But for fifty years it did not wield its constitutional authority. The idea of using Article 19 of the WHA to create a treaty to enforce global tobacco control was first suggested in 1979 . WHO had just produced a tobacco control report and it was suggested that if the report "failed to produce results in a reasonable time" a multilateral binding agreement should be formed. Many were squeamish.

I was born in the 1970s. Evidence had, by then, already accumulated to show that smoking was linked to lung cancer but the longitudinal data that would demonstrate the scale of the hazard that is tobacco smoking had yet to accumulate. In the 1970s people tolerated smoking in a way that horrifies children born in the noughties, many of whom get offended when someone lights up near them. My parents were non smokers but they kept a pile of ashtrays in our house for guests' use. They would never have dreamed of asking anyone not to smoke in our home - that would have been rude! Ditto for the car. If second-hand cigarette smoke made you feel ill then you went outside. There were smoking rooms in high schools. Smokers lit up in shops, restaurants, airplanes, university lectures, theatres and even hospitals. Cigarette advertisements featuring thin, sexy, youthful, healthy-and-strong-looking models with the whitest of white teeth were ubiquitous... kids wanted to be those people. Big Tobacco was booming.

I spent my youth in South Africa, which passed a Tobacco Products Control Bill in 1999 that meant that, by 2000, smoking in public places such as restaurants and malls was illegal in that country. Non-smokers breathed a guilty collective sigh of relief.

When I moved to the UK in 2002 I discovered with some surprise that no such ban existed in the pubs and cinemas of London. The UK seemed distinctly backward. Smoking in public places became illegal in the UK only after its ratification of the FCTC in 2005.

Dr Chan said in her speech today, "When public health policies cross purposes with the interests of powerful economic operators, economic arguments trump public health time and time again. Not this time. Public health won."
But for a while it didn't. Public Health was having a really hard time getting heard over the well-financed marketing and litigating strategies of Big Tobacco. Until the FCTC was signed by 168 countries, ratified by 180 and came into force in February 2005, all the impeccable and copious science had little effect. The treaty legally mandated ratifying governments to act to restrict substantially the marketing and sale of tobacco products.

As Chan said today, "the Framework Convention is an outstanding model of how multiple non-health sectors, and multiple UN agencies, can work together seamlessly to support a health objective. The importance of this model continues to grow as more and more of the 21st century’s biggest threats to health have root causes that lie in non-health sectors."

Does this mean that the tobacco threat is going away? It is not. Chan also acknowledged that "[t]hreats of lengthy and costly litigation are being used to intimidate governments that are trying to do the right thing for their people." And that the "tobacco industry fights hardest against those measure that work best, like price increases, bans on advertising and sponsorship, large pictorial warnings on packages, and plain packaging."

There's much to do yet, not least get the United States to ratify the FCTC! The marketing efforts of Big Tobacco are being redirected, from countries where smoking is declining because of effective public health measures and government legislation, towards recruitment of new smokers in developing countries.

But today is a day to celebrate the great strides that have been made in improving public health through tobacco control. It is a day to celebrate the millions of lives that, as a result, did not end prematurely .